The Elusive Definition of Population Health

The Elusive Definition of Population Health

Population Health isn’t easily defined

A few years ago we saw a massive amount of vendors try to enter into the EMR space. Then it seemed like everyone was an ACO (Accountable Care Organization) expert. Now we have vendors trying to tell you that they have the answer for Population Health.  I was asked recently by a physician to define Population Health. I guess he was expecting a straight clinical definition. When I provided my definition of population health, he sort of raised an eyebrow, and stated that it did not sound like a definition at all, that it sounded more like a process. Of course my response was, “exactly.”

I hate to use this analogy, because I know that it’s been used a lot in the past: A group of people in a dark room with an elephant will only feel and experience one section of the elephant and have their own definition of what it is. I truly believe that is what’s happening with population health.

You see, people that have been focusing on the data will define it as extracts, HL7 feeds, and analytics. Those in the ACO market will define it as a data warehouse that contains information across all the various entities. Then again, those involved with quality initiatives will be heads down evaluating dashboards and analytics to try to drill down on clinical performance measures. Finally, providers want to know about improvement in chronic disease management.  So to me it’s the sum of the whole.


How I define Population Health:

  1. Define quality metrics and align those to local/regional Population Health needs. This involves aligning your organizational strategic objectives with your clinical quality initiatives. Having a roadmap of where you want to go in order to meet your population health requirements.
  2. Pool data and apply the necessary data quality tools to normalize, test and validate the quality of the data. What this means is capturing the wealth of information that you have across the continuum of care. There is a complete strategy and methodology around capturing the data, pulling the information, verifying the quality, and selecting the right tool that will provide you with the level of analysis you need to make informed decisions.
  3. Use a proven real-time, predictive analytics tool and partner with a value base payer to further define objectives. Remember, we are not talking about report cards here. We are talking about providing real sound medical data that clinicians can use to modify, improve, and build on health outcomes.
  4. Actively work with providers to monitor and assist with improving outcomes. The initial roadmap that was created when you embarked on the population health journey, does not have a GPS map voice at the end that says, “you have arrived at your destination.” It’s really meant to guide the clinician through the best practice protocols in treating chronic disease. Once your organization as a whole embraces the process, then you can look at adding additional protocols and metrics.
  5. Improve clinical; financial and patient experience outcomes. Besides the clinical objectives, other metrics concerning cost of medications, treatment plans, and monitoring patient compliance all become part of the population health experience.
  6. LOOP: Return to step 1 and add additional quality metrics. So therefore most organizations start with bite sized goals and once you move through the quality initiative steps you create your own organizational lessons learned and are able to add additional metrics later on.

So if your job function only involves one part of the elephant in the room, it’s time to turn on the light and take a step back. Because in the end, this is really not about value-based reimbursement, green dots on a dashboard, or report cards. This is really about improving the health of you and me as patients.


Discuss your journey and learn from other healthcare executives in the Population Health Management Community!

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